Class : Cath Report Content Document

Class : CathReportContentDocument

Class Name
Cath Report Content Document
Class Kind
TemplateSpecType
Template ID
1.3.6.1.4.1.19376.1.4.1.1.2
Description
This is the template for Cardiac Cath/PCI Reports with discrete data elements as described in the NCDR CathPCI Registry version 4.4 Coder’s Data Dictionary. The Template ID for conformance to this template is OID = 1.3.6.1.4.1.19376.1.4.1.1.2.
Document
IHE Cardiology Technical Framework Supplement – Cath Report Content (CRC) (6.3.2)
Parent
cda-POCDMT000040ClinicalDocument
Package
crc

List of related constraints

  • Cath Report Content SHALL have component/structuredBody (CONF:9589-CRC) (CRC : 6.3.2) more..
  • SHALL contain exactly one [1..1] typeId (CONF:5361) (CRC : 6.3.2) more..
  • typeId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.1.3" (CONF:5250) (CRC : 6.3.2) more..
  • typeId SHALL contain exactly one [1..1] @extension="POCD_HD000040" (CONF:5251) (CRC : 6.3.2) more..
  • recordTarget/patientRole SHALL contain at least one [1..*] telecom (CONF:5280) (CRC : 6.3.2) more..
  • recordTarget SHALL contain exactly one [1..1] patientRole (CONF:5267) (CRC : 6.3.2) more..
  • code SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet ProcedureNoteDocumentTypeCodes 2.16.840.1.113883.11.20.6.1 DYNAMIC (CONF:17183) (CRC : 6.3.2) more..
  • SHALL contain exactly one [1..1] title (CONF:5254). (CRC : 6.3.2) more..
  • SHALL contain exactly one [1..1] confidentialityCode, which SHOULD be selected from ValueSet HL7 BasicConfidentialityKind 2.16.840.1.113883.1.11.16926 STATIC 2010-04-21 (CONF:5259) (CRC : 6.3.2) more..
  • SHALL contain exactly one [1..1] recordTarget (CONF:5266-CRC) (CRC : 6.3.2) more..
  • recordTarget/patientRole SHALL contain at least one [1..*] id (CONF:5268) (CRC : 6.3.2) more..
  • recordTarget/patientRole SHALL contain at least one [1..*] addr (CONF:5271) (CRC : 6.3.2) more..
  • recordTarget/patientRole/addr SHALL contain at least one [1..*] postalCode(CONF:CRC-xxx) (CRC : 6.3.2) more..
  • recordTarget/patientRole SHALL contain exactly one [1..1] patient (CONF:5283) (CRC : 6.3.2) more..
  • recordTarget/patientRole/patient SHALL contain exactly one [1..1] name (CONF:5284) (CRC : 6.3.2) more..
  • recordTarget/patientRole/patient/name SHALL contain exactly one [1..1] family (CONF:7159) (CRC : 6.3.2) more..
  • recordTarget/patientRole/patient/name SHALL contain at least one [1..*] given (CONF:7157) (CRC : 6.3.2) more..
  • recordTarget/patientRole/patient SHALL contain exactly one [1..1] administrativeGenderCode, which SHALL be selected from ValueSet Administrative Gender (HL7 V3) 2.16.840.1.113883.1.11.1 DYNAMIC (CONF:6394) (CRC : 6.3.2) more..
  • recordTarget/patientRole/patient SHALL contain exactly one [1..1] birthTime (CONF:5298) (CRC : 6.3.2) more..
  • recordTarget/patientRole/patient/birthtime SHALL be precise to year (CONF:5299) (CRC : 6.3.2) more..
  • recordTarget/patientRole/patient/birthtime SHOULD be precise to day (CONF:5300) (CRC : 6.3.2) more..
  • SHALL contain at least one [1..*] author (CONF:5444) (CRC : 6.3.2) more..
  • author SHALL contain exactly one [1..1] time (CONF:5445) (CRC : 6.3.2) more..
  • author/assignedAuthor SHALL contain exactly one [1..1] id (CONF:5449) (CRC : 6.3.2) more..
  • author/assignedAuthor SHALL contain at least one [1..*] addr (CONF:5452) (CRC : 6.3.2) more..
  • author/assignedAuthor SHALL contain at least one [1..*] telecom (CONF:5428) (CRC : 6.3.2) more..
  • author/assignedAuthor SHALL contain exactly one [1..1] assignedPerson (CONF:5430-CRC) (CRC : 6.3.2) more..
  • author/assignedAuthor/assignedPerson SHALL contain at least one [1..*] name (CONF:16789) (CRC : 6.3.2) more..
  • SHALL contain exactly one [1..1] custodian (CONF:5519) (CRC : 6.3.2) more..
  • custodian SHALL contain exactly one [1..1] assignedCustodian (CONF:5520) (CRC : 6.3.2) more..
  • custodian/assignedCustodian SHALL contain exactly one [1..1] representedCustodianOrganization (CONF:5521) (CRC : 6.3.2) more..
  • custodian/assignedCustodian/representedCustodianOrganization SHALL contain at least one [1..*] id (CONF:5522) (CRC : 6.3.2) more..
  • custodian/assignedCustodian/representedCustodianOrganization SHALL contain exactly one [1..1] name (CONF:5524) (CRC : 6.3.2) more..
  • inFulfillmentOf elements, if present, SHALL contain exactly one [1..1] order (CONF:9953-CRC) (CRC : 6.3.2) more..
  • custodian/assignedCustodian/representedCustodianOrganization SHALL contain exactly one [1..1] telecom (CONF:5525) (CRC : 6.3.2) more..
  • custodian/assignedCustodian/representedCustodianOrganization SHALL contain at least one [1..*] addr (CONF:5559) (CRC : 6.3.2) more..
  • SHALL contain exactly one [1..1] legalAuthenticator (CONF:5579-CRC). (CRC : 6.3.2) more..
  • legalAuthenticator SHALL contain exactly one [1..1] time (CONF:5580) (CRC : 6.3.2) more..
  • legalAuthenticator SHALL contain exactly one [1..1] signatureCode (CONF:5583) (CRC : 6.3.2) more..
  • signatureCode SHALL contain exactly one [1..1] @code="S" (CodeSystem: Participationsignature 2.16.840.1.113883.5.89) (CONF:5584) (CRC : 6.3.2) more..
  • legalAuthenticator SHALL contain exactly one [1..1] assignedEntity (CONF:5585) (CRC : 6.3.2) more..
  • legalAuthenticator/assignedEntity SHALL contain at least one [1..*] id (CONF:5586) (CRC : 6.3.2) more..
  • legalAuthenticator/assignedEntity MAY contain zero or one [0..1] code (CONF:17000-CRC) (CRC : 6.3.2) more..
  • legalAuthenticator/assignedEntity SHALL contain at least one [1..*] addr (CONF:5589) (CRC : 6.3.2) more..
  • legalAuthenticator/assignedEntity SHALL contain at least one [1..*] telecom (CONF:5595) (CRC : 6.3.2) more..
  • legalAuthenticator/assignedEntity/telecom SHOULD contain @use (CONF:7999-CRC) (CRC : 6.3.2) more..
  • legalAuthenticator/assignedEntity SHALL contain exactly one [1..1] assignedPerson (CONF:5597) (CRC : 6.3.2) more..
  • legalAuthenticator/assignedEntity assignedPerson SHALL contain at least one [1..*] name (CONF:5598) (CRC : 6.3.2) more..
  • MAY contain zero or more [0..*] authenticator (CONF:5607) (CRC : 6.3.2) more..
  • authenticator SHALL contain exactly one [1..1] time (CONF:5608) (CRC : 6.3.2) more..
  • authenticator SHALL contain exactly one [1..1] signatureCode (CONF:5610) (CRC : 6.3.2) more..
  • authenticator/signatureCode SHALL contain exactly one [1..1] @code="S" (CodeSystem: Participationsignature 2.16.840.1.113883.5.89) (CONF:5611) (CRC : 6.3.2) more..
  • authenticators, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:5612). (CRC : 6.3.2) more..
  • authenticator/assignedEntity SHALL contain at least one [1..*] id (CONF:5613) (CRC : 6.3.2) more..
  • authenticator/assignedEntity SHALL contain at least one [1..*] addr (CONF:5616). (CRC : 6.3.2) more..
  • authenticator/assignedEntity SHALL contain at least one [1..*] telecom (CONF:5622). (CRC : 6.3.2) more..
  • authenticator/assignedEntity SHALL contain exactly one [1..1] assignedPerson (CONF:5624) (CRC : 6.3.2) more..
  • authenticator/assignedEntity/assignedPerson SHALL contain at least one [1..*] name (CONF:5625) (CRC : 6.3.2) more..
  • MAY contain zero or one [0..1] inFulfillmentOf (CONF:9952-CRC) (CRC : 6.3.2) more..
  • inFulfillmentOf/order SHALL contain at least one [1..*] id (CONF:9954) (CRC : 6.3.2) more..
  • inFulfillmentOf/order SHALL contain at least one [1..*] priorityCode which SHALL be selected from ValueSet ActPriority Value Set 2.16.840.1.113883.1.11.16866 DYNAMIC (CONF:8300-CRC) (CRC : 6.3.2) more..
  • MAY contain zero or more [0..*] authorization (CONF:16792) (CRC : 6.3.2) more..
  • authorization SHALL contain exactly one [1..1] consent. (CONF:16793) (CRC : 6.3.2) more..
  • authorization/consent SHALL contain exactly one [1..1] statusCode (CONF:16797). This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:16798) (CRC : 6.3.2) more..
  • SHALL contain exactly one [1..1] componentOf (CONF:9955-CRC) (CRC : 6.3.2) more..
  • componentOf element SHALL contain exactly one [1..1] encompassingEncounter (CONF:9956) (CRC : 6.3.2) more..
  • componentOf/encompassingEncounter SHALL contain at least one [1..*] id (CONF:9959) (CRC : 6.3.2) more..
  • componentOf/encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:9958) (CRC : 6.3.2) more..
  • componentOf/encompassingEncounter/effectiveTime SHALL be accurate to the day and MAY be accurate to the second (CONF:CRC-xxx) (CRC : 6.3.2) more..
  • componentOf/encompassingEncounter SHALL contain exactly one [1..1] code (CONF:8501) (CRC : 6.3.2) more..
  • componentOf/encompassingEncounter SHALL contain at least one [1..*] location/healthCareFacility (CONF:8500) (CRC : 6.3.2) more..
  • componentOf/encompassingEncounter/location/healthCareFacility SHALL contain at least one [1..*] code representing the type of location (CONF:CRC) (CRC : 6.3.2) more..
  • componentOf/encompassingEncounter/location/healthCareFacility SHALL contain at least one [1..*] id (CONF:8500). (CRC : 6.3.2) more..
  • componentOf/encompassingEncounter/location/healthCareFacility SHOULD contain at least one [1..*] serviceProviderOrganization (CONF:CRC-xxx) (CRC : 6.3.2) more..
  • componentOf/encompassingEncounter/location/healthCareFacility/serviceProviderOrganization SHALL contain at least one [1..*]name (CONF:CRC-xxx). (CRC : 6.3.2) more..
  • Only One [0..1] section Anesthesia Section (2.16.840.1.113883.10.20.22.2.25) is allowed (CRC, Table 6.3.3-1) more..
  • componentOf/encompassingEncounter/location/healthCareFacility/serviceProviderOrganization SHALL contain at least one [1..*] addr (CONF:CRC-xxx) (CRC : 6.3.2) more..
  • Only One [0..1] section Procedure Specimens Taken Section (2.16.840.1.113883.10.20.22.2.31) is allowed (CRC, Table 6.3.3-1) more..
  • componentOf/encompassingEncounter/location/healthCareFacility/serviceProviderOrganization SHALL contain at least one [1..*] telecom (CONF:CRC-xxx) (CRC : 6.3.2) more..
  • componentOf/encompassingEncounter/location/healthCareFacility/location SHALL contain at least one [1..*]name and/or addr to identify the place of the encounter (CONF:CRC-xxx) (CRC : 6.3.2) more..
  • componentOf/encompassingEncounter MAY contain zero to four [0..4] encounterParticipant (CONF:8502-CRC) (CRC : 6.3.2) more..
  • componentOf/encompassingEncounter MAY contain zero to four [0..4] encounterParticipant (CONF:8502-CRC) such that it MAY contain at most two [0..2] @typeCode="REF" Referrer (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) for the referring cardiologist and referring physician (CONF:8503-CRC) (CRC : 6.3.2) more..
  • componentOf/encompassingEncounter MAY contain zero to four [0..4] encounterParticipant (CONF:8502-CRC) such that it MAY contain zero or one [0..1] @typeCode="ATND" Physician of Record (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:8503-CRC) (CRC : 6.3.2) more..
  • SHALL contain exactly one [1..1] documentationOf (CONF:8510-CRC) (CRC : 6.3.2) more..
  • documentationOf SHALL contain exactly one [1..1] serviceEvent (CONF:10061) (CRC : 6.3.2) more..
  • The value of documentationOf/serviceEvent/code SHOULD be selected from SNOMED CT (codeSystem 2.16.840.1.113883.6.96) and MAY be selected from a localized procedure coding system for a given country such as ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104 ) or CPT-4 (codeSystem 2.16.840.1.113883.6.12) in the U.S. (CONF:CRC-xxx) (CRC : 6.3.2) more..
  • documentationOf/serviceEvent SHALL contain at least one [1..*] id values including the Study Instance UID used in the DICOM imaging data, with the UID value in the root attribute (CONF:CRC-xxx) (CRC : 6.3.2) more..
  • documentationOf/serviceEvent SHALL contain exactly one [1..1] effectiveTime (CONF:10062) (CRC : 6.3.2) more..
  • documentationOf/serviceEvent/effectiveTime SHALL contain exactly one [1..1] low (CONF:26449) (CRC : 6.3.2) more..
  • documentationOf/serviceEvent/effectiveTime , If a width is not present, the serviceEvent/effectiveTime SHALL include effectiveTime/high (CONF:8514) (CRC : 6.3.2) more..
  • documentationOf/serviceEvent/effectiveTime SHALL be accurate to the day and MAY be accurate to the second (CONF:CRC-xxx) (CRC : 6.3.2) more..
  • documentationOf/serviceEvent SHALL contain at least one [1..*] performer (CONF:8520-CRC) (CRC : 6.3.2) more..
  • Only One [0..1] section Plan of Care – Cardiac Section (1.3.6.1.4.1.19376.1.4.1.2.22) is allowed (CRC, Table 6.3.3-1) more..
  • documentationOf/serviceEvent SHALL contain one or two [1..2] @typeCode="PPRF" Primary Performer (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90). This is for the case where both a cath and PCI are performed in the same procedure. (CONF:8521-CRC) (CRC : 6.3.2) more..
  • documentationOf/serviceEvent/performer SHALL contain exactly one [1..1] assignedEntity (CONF:14911) (CRC : 6.3.2) more..
  • documentationOf/serviceEvent/performer/assignedEntity SHOULD contain zero or one [0..1] code (CONF:14912) (CRC : 6.3.2) more..
  • Medical History - Cardiac Section (1.3.6.1.4.1.19376.1.4.1.2.17) is a required section [1..1] (CRC, Table 6.3.3-1) (CRC : 6.3.2) more..
  • Allergies Section (2.16.840.1.113883.10.20.22.2.6) is a required section [1..1] (CRC, Table 6.3.3-1) (CRC : 6.3.2) more..
  • Physical Exam Section (2.16.840.1.113883.10.20.2.10) is a required section [1..1] (CRC, Table 6.3.3-1) (CRC : 6.3.2) more..
  • Vital Signs Section(2.16.840.1.113883.10.20.22.2.4) is a required section [1..1] (CRC, Table 6.3.3-1) (CRC : 6.3.2) more..
  • Pre-Procedure Results – Cardiac Section (1.3.6.1.4.1.19376.1.4.1.2.23) is a required section [1..1] (CRC, Table 6.3.3-1) (CRC : 6.3.2) more..
  • Planned Procedure Section(2.16.840.1.113883.10.20.22.2.30) is a required section [1..1] (CRC, Table 6.3.3-1) (CRC : 6.3.2) more..
  • Procedure Indications Section(2.16.840.1.113883.10.20.22.2.29) (CRC, Table 6.3.3-1) is a required section [1..1] (CRC, Table 6.3.3-1) (CRC : 6.3.2) more..
  • Medications Administered Section (2.16.840.1.113883.10.20.22.2.38) (CRC, Table 6.3.3-1) is a required section [1..1] (CRC, Table 6.3.3-1) (CRC : 6.3.2) more..
  • Procedure Description - Cardiac Section (1.3.6.1.4.1.19376.1.4.1.2.19) (CRC, Table 6.3.3-1) is a required section [1..1] (CRC, Table 6.3.3-1) (CRC : 6.3.2) more..
  • Procedure Disposition Section (2.16.840.1.113883.10.20.18.2.12) (CRC, Table 6.3.3-1) is a required section : R[1..1] (CRC, Table 6.3.3-1) (CRC : 6.3.2) more..
  • Complications Section (2.16.840.1.113883.10.20.22.2.37) (CRC, Table 6.3.3-1) is a required section : R[1..1] (CRC, Table 6.3.3-1) (CRC : 6.3.2) more..
  • Procedure Results - Cardiac Section (1.3.6.1.4.1.19376.1.4.1.2.20) (CRC, Table 6.3.3-1) is a required section : R[1..1] (CRC, Table 6.3.3-1) (CRC : 6.3.2) more..
  • Postprocedure Diagnosis Section (2.16.840.1.113883.10.20.22.2.36) (CRC, Table 6.3.3-1) is a required section : R[1..1] (CRC, Table 6.3.3-1) (CRC : 6.3.2) more..
  • Only One [0..1] section Document Summary Section(1.3.6.1.4.1.19376.1.4.1.2.16) is allowed (CRC, Table 6.3.3-1) more..
  • Only One [0..1] section Family History Section (2.16.840.1.113883.10.20.22.2.15) is allowed (CRC, Table 6.3.3-1) more..
  • Only One [0..1] section Social History Section (2.16.840.1.113883.10.20.22.2.17) is allowed (CRC, Table 6.3.3-1) more..
  • Only One [0..1] section Key Images – Cardiac Section (1.3.6.1.4.1.19376.1.4.1.2.21) is allowed (CRC, Table 6.3.3-1) more..
  • Only One [0..1] sectionDICOM Object Catalog Section (2.16.840.1.113883.10.20.6.1.1) is allowed (CRC, Table 6.3.3-1) more..